Cubans say they offer health care to the world's poor because they have big hearts. But what do they get in return?

They live longer than almost anyone in Latin America. Far fewer babies die. Almost everyone has been vaccinated, and such scourges of the poor as parasites, TB, malaria, even HIV/AIDS are rare or non-existent. Anyone can see a doctor, at low cost, right in the neighborhood.

The Cuban health care system is producing a population that is as healthy as those of the world's wealthiest countries at a fraction of the cost. And now Cuba has begun exporting its system to under-served communities around the world -- including the United States.

The story of Cuba's health care ambitions is largely hidden from the people of the United States, where politics left over from the Cold War maintain an embargo on information and understanding. But it is increasingly well-known in the poorest communities of Latin America, the Caribbean, and parts of Africa where Cuban and Cuban-trained doctors are practicing.

In the words of Dr. Paul Farmer, Cuba is showing that "you can introduce the notion of a right to health care and wipe out the diseases of poverty."

Health Care for All Cubans

Many elements of the health care system Cuba is exporting around the world are common-sense practices. Everyone has access to doctors, nurses, specialists, and medications. There is a doctor and nurse team in every neighborhood, although somewhat fewer now, with 29,000 medical professionals serving out of the country -- a fact that is causing some complaints. If someone doesn't like their neighborhood doctor, they can choose another one.

House calls are routine, in part because it's the responsibility of the doctor and nurse team to understand you and your health issues in the context of your family, home, and neighborhood. This is key to the system. By catching diseases and health hazards before they get big, the Cuban medical system can spend a little on prevention rather than a lot later on to cure diseases, stop outbreaks, or cope with long-term disabilities. When a health hazard like dengue fever or malaria is identified, there is a coordinated nationwide effort to eradicate it. Cubans no longer suffer from diphtheria, rubella, polio, or measles and they have the lowest AIDS rate in the Americas, and the highest rate of treatment and control of hypertension.

For health issues beyond the capacity of the neighborhood doctor, polyclinics provide specialists, outpatient operations, physical therapy, rehabilitation, and labs. Those who need inpatient treatment can go to hospitals; at the end of their stay, their neighborhood medical team helps make the transition home. Doctors at all levels are trained to administer acupuncture, herbal cures, or other complementary practices that Cuban labs have found effective. And Cuban researchers develop their own vaccinations and treatments when medications aren't available due to the blockade, or when they don't exist.

Exporting Health Care

For decades, Cuba has sent doctors abroad and trained international students at its medical schools. But things ramped up beginning in 1998 when Hurricanes George and Mitch hammered Central America and the Caribbean. As they had often done, Cuban doctors rushed to the disaster zone to help those suffering the aftermath. But when it was time to go home, it was clear to the Cuban teams that the medical needs extended far beyond emergency care. So Cuba made a commitment to post doctors in several of these countries and to train local people in medicine so they could pick up where the Cuban doctors left off. ELAM, the Havana-based Latin American School of Medicine, was born, and with it the offer of 10,000 scholarships for free medical training.

Today the program has grown to 22,000 students from Latin America, the Caribbean, Africa, Asia, and the United States who attend ELAM and 28 other medical schools across Cuba. The students represent dozens of ethnic groups, 51 percent are women, and they come from more than 30 countries. What they have in common is that they would otherwise be unable to get a medical education. When a slum dweller in Port au Prince, a young indigenous person from Bolivia, the son or daughter of a farmer in Honduras, or a street vendor in the Gambia wants to become a doctor, they turn to Cuba. In some cases, Venezuela pays the bill. But most of the time, Cuba covers tuition, living expenses, books, and medical care. In return, the students agree that, upon completion of their studies, they will return to their own under-served communities to practice medicine.

The curriculum at ELAM begins, for most students, with up to a year of "bridging" courses, allowing them to catch up on basic math, science, and Spanish skills. The students are treated for the ailments many bring with them.

At the end of their training, which can take up to eight years, most students return home for residencies. Although they all make a verbal commitment to serve the poor, a few students quietly admit that they don't see this as a permanent commitment.

One challenge of the Cuban approach is making sure their investment in medical education benefits those who need it most. Doctors from poor areas routinely move to wealthier areas or out of the country altogether. Cuba trains doctors in an ethic of serving the poor. They learn to see medical care as a right, not as a commodity, and to see their own role as one of service. Stories of Cuban doctors who practice abroad suggest these lessons stick. They are known for taking money out of their own pockets to buy medicine for patients who can't afford to fill a prescription, and for touching and even embracing patients.

Cuba plans with the help of Venezuela to take their medical training to a massive scale and graduate 100,000 doctors over the next 15 years, according to Dr. Juan Ceballos, advisor to the vice minister of public health. To do so, Cuba has been building new medical schools around the country and abroad, at a rapid clip.

But the scale of the effort required to address current and projected needs for doctors requires breaking out of the box. The new approach is medical schools without walls. Students meet their teachers in clinics and hospitals, in Cuba and abroad, practicing alongside their mentors. Videotaped lectures and training software mean students can study anywhere there are Cuban doctors. The lower training costs make possible a scale of medical education that could end the scarcity of doctors.

U.S. Students in Cuba

Recently, Cuba extended the offer of free medical training to students from the United States. It started when Representative Bennie Thompson of Mississippi got curious after he and other members of the Congressional Black Caucus repeatedly encountered Cuban or Cuban-trained doctors in poor communities around the world.

They visited Cuba in May 2000, and during a conversation with Fidel Castro, Thompson brought up the lack of medical access for his poor, rural constituents. "He [Castro] was very familiar with the unemployment rates, health conditions, and infant mortality rates in my district, and that surprised me," Thompson said. Castro offered scholarships for low-income Americans under the same terms as the other international students -- they have to agree to go back and serve their communities.

Today, about 90 young people from poor parts of the United States have joined the ranks of international students studying medicine in Cuba.

The offer of medical training is just one way Cuba has reached out to the United States. Immediately after Hurricanes Katrina and Rita, 1,500 Cuban doctors volunteered to come to the Gulf Coast. They waited with packed bags and medical supplies, and a ship ready to provide backup support. Permission from the U.S. government never arrived.

"Our government played politics with the lives of people when they needed help the most," said Representative Thompson. "And that's unfortunate."

When an earthquake struck Pakistan shortly afterwards, though, that country's government warmly welcomed the Cuban medical professionals. And 2,300 came, bringing 32 field hospitals to remote, frigid regions of the Himalayas. There, they set broken bones, treated ailments, and performed operations for a total of 1.7 million patients.

The disaster assistance is part of Cuba's medical aid mission that has extended from Peru to Indonesia, and even included caring for 17,000 children sickened by the 1986 accident at the Chernobyl nuclear plant in the Ukraine.

It isn't only in times of disaster that Cuban health care workers get involved. Some 29,000 Cuban health professionals are now practicing in 69 countries -- mostly in Latin America, the Caribbean, and Africa. In Venezuela, about 20,000 of them have enabled President Hugo Chávez to make good on his promise to provide health care to the poor. In the shantytowns around Caracas and the banks of the Amazon, those who organize themselves and find a place for a doctor to practice and live can request a Cuban doctor.

As in Cuba, these doctors and nurses live where they serve, and become part of the community. They are available for emergencies, and they introduce preventative health practices.

Some are tempted to use their time abroad as an opportunity to leave Cuba. In August, the U.S. Department of Homeland Security announced a new policy that makes it easier for Cuban medical professionals to come to the U.S. But the vast majority remain on the job and eventually return to Cuba.

Investing in Peace

How do the Cuban people feel about using their country's resources for international medical missions? Those I asked responded with some version of this: We Cubans have big hearts. We are proud that we can share what we have with the world's poor.

Nearly everyone in Cuba knows someone who has served on a medical mission. These doctors encounter maladies that have been eradicated from Cuba. They expand their understanding of medicine and of the suffering associated with poverty and powerlessness, and they bring home the pride that goes with making a difference.

And pride is a potent antidote to the dissatisfaction that can result from the economic hardships that continue 50 years into Cuba's revolution.

From the government's perspective, their investment in medical internationalism is covered, in part, by ALBA, the new trade agreement among Venezuela, Bolivia, Nicaragua and Cuba. ALBA, an alternative to the Free Trade Area of the Americas, puts human needs ahead of economic growth, so it isn't surprising that Cuba's health care offerings fall within the agreement, as does Venezuelan oil, Bolivian natural gas, and so on. But Cuba also offers help to countries outside of ALBA.

"All we ask for in return is solidarity," Dr. Ceballos says.

"Solidarity" has real-world implications. Before Cuba sent doctors to Pakistan, relations between the two countries were not great, Ceballos says. But now the relationship is "magnificent." The same is true of Guatemala and El Salvador. "Although they are conservative governments, they have become more flexible in their relationship with Cuba," he says.

Those investments in health care missions "are resources that prevent confrontation with other nations," Ceballos explains. "The solidarity with Cuba has restrained aggressions of all kinds." And in a statement that acknowledges Cuba's vulnerabilities on the global stage, Ceballos puts it this way: "It's infinitely better to invest in peace than to invest in war."

Imagine, then, that this idea took hold. Even more revolutionary than the right to health care for all is the idea that an investment in health -- or in clean water, adequate food or housing -- could be more powerful, more effective at building security than bombers and aircraft carriers.

Sarah van Gelder, executive editor of YES!, was in Cuba (legally) in December 2006 visiting medical schools, clinics, and hospitals. Her travel was supported by The Atlantic Philanthropies, and MEDICC provided program consulting.